Thoracic Outlet Syndrome | Vascular Center of Wichita Falls

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Thoracic Outlet Syndrome

What is thoracic outlet syndrome (TOS)?

The thoracic outlet is basically two spaces.  The first space is between your collarbone, clavicle, first rib and anterior scalene muscle.  This space contains the vein returning blood flow from your arm to your heart.  The second space is the area between the anterior scalene muscle, middle scalene muscle and first rib.  This space contains the brachial plexus (nerve to your arm) and the artery to your arm.  This narrow passageway is crowded with blood vessels, muscles and nerves.  If the shoulder muscles are not strong enough to hold the shoulder in place, it can ride lower thus putting pressure on the nerves and blood vessels.  This causes a variety of symptoms which together are known as thoracic outlet syndrome.

Most doctors agree that TOS is caused by compression of the brachial plexus or subclavian vessels as they pass through narrow passageways leading from the base of the neck to the armpit and arm.  This can occur from an injury and general postural changes or from repetitive work with your arms too low.

Thoracic outlet problems break down into three categories:

To further clarify, the brachial plexus is a network of nerves that come out of the vertebrae in your neck and go together to form bundles of nerves that branch and go to the sides of your neck, your shoulder and your arm.   These nerves begin at the spinal cord in the neck and control the hand, wrist, elbow, and shoulder.  Nerves are our electrical wiring system that carry messages from the brain to the rest of the body.  A nerve is like an electrical cable wrapped in insulation.

Motor nerves carry messages from the brain to muscles to make the body move.  Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature.  The brachial plexus has nerves that are both motor and sensory.

What happens when the brachial plexus is injured?

The network of nerves is fragile and can be damaged by pressure, stretching, or cutting.  Stretching can occur when the head and neck are forced away from the shoulder, such as might happen in a fall off a horse or bicycle or motorcycle.  This can also occur in some types of weightlifting injuries and also with pitching a baseball.

Injury to a nerve

Injury to a nerve can stop the signals going to and from the brain thereby preventing the muscles of the arm and hand from working properly and causing loss of feeling in the area supplied by the injured nerve. When a nerve is cut, both the nerve and the insulation are broken.  Pressure or stretching injuries can cause the fibers that carry the information to break and stop the nerve from working even without damaging the cover.

When nerve fibers are cut, the end of the fiber farthest from the brain dies while the insulation stays healthy.  The end that is closest to the brain does not die and after some time the nerve may begin to heal.  If the insulation was not cut, new fibers may grow down the empty cover of the tissue until reaching a muscle or sensory receptor.

Some brachial plexus injuries are minor and will completely recover in several weeks.  Other injuries are severe enough that some permanent disability involving the arm can occur.

How is a brachial plexus injury treated?

Many brachial plexus injuries can recover with time and therapy.  The time for recovery can be weeks or months.  When an injury is unlikely to improve, several surgical techniques can be used to improve recovery.  To help decide which injuries are likely to recover, your doctor will rely upon multiple examinations of the arm and hand to check the strength of muscles and sensation.  Additional testing, such as an MRI scan or CT scan, may be used to visually evaluate the brachial plexus.  An EMG and nerve conduction study, a test that measures the electrical activity transmitted by nerves and muscles, may also be performed.  In some cases, repair of the nerves or transfer of undamaged nerves from other areas of the body can be performed.  In other cases, transfer of functioning muscles (tendon transfer) to take over areas of lost function can be performed.

What is my role in recovery and what kind of results can I expect?

The patient must do several things to keep up muscle activity and prevent the joints from getting stiff.  Your doctor may recommend therapy to keep joints flexible.  If the joints become stiff, they will not work even after muscles begin to work again.  When a sensory nerve has been injured and feeling is affected, the patient must be extra careful not to burn or cut fingers.  After the nerve has recovered, the brain gets lazy and a procedure called sensory re-education may be needed to improve feeling in the hand or finger.  Your doctor will recommend the appropriate therapy based on the nature of your injury.

Factors that may affect results after brachial plexus injury include age and the type of injury, severity and location of the injury.  Although brachial plexus injuries may result in lasting problems for the patient, care by a physician and proper therapy can maximize function.

Injury to the artery

The artery most commonly injured is the subclavian artery as it goes over the first rib and becomes an axillary artery.  Repetitive injury to this causes degeneration of this artery and it may respond by forming an aneurysm (ballooned out artery) or thrombosing.  The aneurysm is from repetitive injury to the artery in someone with thoracic outlet syndrome.  The aneurysm can thrombose or shower blood clots from within it to the fingers and hand.  The artery can just spontaneously occlude but usually does not happen until there is aneurysm formation.

Another common injury in baseball pitchers occurs at the distal axillary artery, proximal brachial artery or an artery branches off and goes around the proximal humerus bone in your upper arm.  This can cause the artery to thrombose at this level.

Injury to the vein

This most commonly occurs in weighlifters, in someone who exercises aggressively and usually body builders.  It can occur in baseball pitchers.  It can occur after a fracture of the collarbone proximally in which there is a large callus formation or deformity of the collarbone causing pressure on the vein.

The thrombosis related to exercise is known as "effort thrombosis" or Paget Schrötter syndrome.

What are the causes and risk factors?

In general, the cause of thoracic outlet syndrome is compression of the nerves and blood vessels in the thoracic outlet, just under your collarbone (clavicle).  The cause of the compression varies and can include:

What are the signs and symptoms?

Generally, there are three types of thoracic outlet syndrome:

Thoracic outlet syndrome is very hard to diagnose in some people and may require visits to your doctor for one to six months before the diagnosis becomes obvious.

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed.  When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome often include:

Symptoms may vary depending on which nerves or blood vessels are compressed.  Symptoms from nerve compression are much more common than symptoms from blood vessel compression.

Signs and symptoms of vascular thoracic outlet syndrome—compression of one or more of your veins and arteries—can include:

You should see your doctor if you experience any of these symptoms.

How is TOS diagnosed?

Making the diagnosis of TOS even more difficult is that a number of disorders cause symptoms similar to those of TOS including rotator cuff injuries, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome, and tumors on the spinal cord.  Your doctor's evaluation will always include a physical exam and detailed medical history and any combination of tests designed to provoke your symptoms (provocation tests) and imaging studies and studies of your nerves. 

Physical exam.  Your doctor will perform a physical examination to look for external signs of thoracic outlet syndrome, such as a depression in your shoulder, a pale discoloration in your arm or limited range of motion.  Other signs are tenderness to palpation over your brachial plexus with movement of your head to the opposite side, and occasionally even to the same side, increased tenderness in your arm with movement.

Medical history.  Your doctor will also ask about your medical history and symptoms, as well as your occupation and physical activities.

Provocation testsProvocation tests are designed to reproduce your symptoms.  The tests may help your doctor determine the cause of your condition and also will help rule out other causes that may have similar symptoms.  Some of the more common provocation tests that can suggest the presence of thoracic outlet syndrome include:

Imaging and nerve study.  To confirm the diagnosis of thoracic outlet syndrome, your doctor may also order one or more of the following tests:

What is the treatment for TOS?

If there is an occlusion of the artery to your arm or the vein or a stretch injury with numbness, this is an emergency.  Go to the emergency room.

In most cases, a conservative approach to treatment is effective in mild neurologic TOS as well as mild arterial TOS and mild venous TOS, especially when the condition is diagnosed early.  Treatment for mild problems may include:

Physical Therapy.  You will learn how to do exercises that strengthen your shoulder muscles to open the thoracic outlet, improve your range of motion and improve your posture.  These exercises, done over time (3 to 6 months), will take the pressure off your blood vessels and nerves in the thoracic outlet.  Here are seven that your doctor will work with you on an individual basis to determine how many repetitions you should do, how often you should do them and the amount of weights, if any, you should use as well as when to make any increase in each exercise.

These exercises should all be done while maintaining perfect posture.  These are best done in front of a mirrow.  If you start to get tired, your posture will change and you will start to cheat.

These exercises will be the only exercises you do for the first few months.

We do not want you to try to build up pectoralis muscles on your chest.  We want them to be flabby, soft and flat so they do not pull your shoulders forward.  Sorry!

As with all exercise programs, if any of these movements cause pain, stop that particular exercise and notify your doctor immediately so your routine can be adjusted.

Thanks to Dr. Dan Bartel for this program that he made me do. 

Relaxation.  Techniques that help you relax, such as deep breathing, can keep you from tensing your shoulders and remind you to maintain good posture.

Medications.  Your doctor may prescribe pain medications, muscle relaxants and non-steroidal anti-inflammatory drugs such as ibuprofen, to decrease inflammation and encourage muscle relaxation. 

Only in emergency situations are other medications used that may include a thrombolytic to break up blood clots and an anticoagulant to prevent clots.  There will usually be associated surgery for your thoracic outlet syndrome at this time or at a short interval afterwards.

If conservative treatment appears initially to be all that is needed yet does not relieve the pain, a recommendation may be made for thoracic outlet decompression surgery to release or remove the structures causing compression of the nerve or artery or vein.

Surgical options

We recommend you do everything possible in the way of physical therapy to avoid having surgery, but surgery may be unavoidable.

Surgery is often effective in relieving pain associated with thoracic outlet syndrome. If you have had problems for an extended period of time and your muscles are weak and cannot be built up prior to surgery, the postoperative recuperative period will be longer.

A specialist in thoracic surgery or vascular surgery will perform the procedure.  All surgical options to treat thoracic outlet syndrome pose a significant risk of injury to the brachial plexus.  The most common surgical approaches for thoracic outlet syndrome treatment are:

Weight loss

If you are overweight, your doctor may recommend that you begin a weight loss program.  Being overweight can stress the shoulder muscles that support your collarbone.  Being significantly overweight may make surgical exposure harder.

If you are body building, stop immediately.  Heavy muscles make surgical exposure more difficult.

Thoracic outlet syndrome that goes untreated for years can cause permanent neurological damage and permanent damage to the artery and permanent damage to the vein that empties your arm, so it is important to deal with the symptoms early.

Prevention

Thoracic outlet syndrome that goes untreated for years can cause permanent neurological injury, injury to the artery or vein so it is important to deal with the symptoms early.  Whether or not you are susceptible to thoracic outlet compression, be aware of your posture and work environment and do the following:

Even if you don't have symptoms of thoracic outlet syndrome, observe the following:

Again we emphasize the need to seek medical consultation right away if you experience any symptoms of a thoracic outlet syndrome of decreased flow to your hand or arms or any symptoms of venous thrombosis (sudden swelling of your arm) often associated with increased size of veins in your arms or shoulder.  Delay can result in permanent damage.

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We hope the information on these pages is both informative and helpful, but it is intended for education only.  Please do note that no web site, no matter how much information is shared, can replace a consultation with your doctor and a vascular specialist.  Medical technology and treatment are continually improving and evolving so before making any decision on treatment, it is always advisable to see your doctor first for a comprehensive evaluation of your vascular disease and other medical conditions.

At the Vascular Center of Wichita Falls, we work closely with your other physicians.  If you have concerns about your arteries or veins, contact us.  A referral is not necessary to make an appointment.

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